I’ve never been in a country while a coup d’etat is happening. This afternoon, while at the staff compound, our team hushes while listening carefully to BBC Africa. Every now and again there’s a brief gap in the Africa-cup soccer tournament, and they talk about Chad’s predicament. These moments have a palpable sense of immediacy, and I find myself more than a bit nervous, albeit despite the facts on the ground, it still feels somewhat abstract. There are no signs of imminent danger for us, as Farchana is a dusty town far from the big cities, but we’re on the main road, and who knows what the next few days will bring.

But the mood in the camp this morning was not set by this event. Which is, in itself, kind of remarkable. Children still play everywhere, water is collected, and the line-up at the Health Centre is long. Looking around the camp, one does not have any sense of political stuff going down. My first meeting this morning was with the team of Community Health Workers (CHWs). My role here is to supervise mental health as well as community health. Which I’m very happy about, as the two go hand-in-hand, but I’ll write more on this later.

 

The camp is split up into about 27 “blocks,” and twenty Sudanese refugees, hired and paid by MSF, are responsible for their designated areas, comprising between 600 and 2000 persons. Really, who better to ask to understand life on the ground? the only reason that “grass-roots” is a metaphor is because it’s the dry season.

We sit on mats on the floor, shoes off, and I asked people to sit in a circle rather than in rows facing front. It is odd at first, because the women were sitting on one side and now we’re all side-by-side, but it flies well enough. Some men insist that they will not sit near the women.  After introductions (translated from French to Masalit), I ask what the main concerns are for them, their families, and their block inhabitants. This is what was discussed (in the order raised, in case you’re wondering):

1) Some of the pit latrines are full in a number of the blocks, and in block K, they’re all full; they have to walk to another block.  SECADEV (a Christian aid and development outfit) handles this, and they’re behind in digging new pits. It is a massive health problem, really. Pit latrines may have done more to decrease morbidity and mortality than anything else… more than vaccinations, more than economic reform, more than food distribution improvements. Simple hygiene goes a long, long way.  The lack of pit latrines, such an easy and cost-efficient means of decreasing morbidity (sickness and suffering) is incredibly frustrating to me.

2) “We need another Mobile Zero.” The pick-up trucks are numbered “mobile 1” to “mobile 50”.  There are not fifty trucks, but the numbers just happened this way for no fathomable reason.  Someone decided to call the donkey-drawn carts (that transport the non-ambulatory patients to and from the Health Center) “mobile zero.” Initially, it’s kind of amusing in an eighteenth-century way, but I quickly realize how crucial these carts are. I’m told that if a patient waits too long for the cart, they may miss the day-time clinic hours and will have to wait for the emergency clinic. This latter clinic, which MSF runs 24 hours, is farther from the camp, and, if need be, the MSF trucks are used for transport. Either way, people want another cart, and they want it to run on Sundays, too.

3) For several reasons, people in the camp are not taking prescribed medications once diagnosed with malaria, and they are dying because of it (though statistics from our health centre don’t show this). They say that people don’t take meds because of side-effects, which they know are clearly better than death, but are not initially viewed as troublesome as a trip to the “marabou,” a traditional healer. Competing explanatory models of illness sometimes conflict, and I heard the story of one marabou announcing that people die even if they take the anti-malarials, so what is the use? I do not know if this view is prevalent, but the conversation this morning indicated that it wasn’t uncommon. My initial impression is that people take the medications, experience side effects, and stop them, deciding to see a marabou instead. I’ve got no truck with the marabous (in fact, I’m looking forward to organizing a meeting with some of them), but there is a big problem with taking drugs sporadically. It goes like this: antibiotics kill off malaria parasites, which are all a bit different. The most susceptible get knocked-off first, and the most resistant take a full course of the meds to be wiped out. But if you stop the course early, you eradicate all but the hardiest strains, and then those multiply and spread. It’s bad for the individual, and bad for the population. The CHWs want another education campaign around malaria, it’s symptoms and treatment.

4) Violence. Every day, about 50-100 women leave the camp, most often in groups, to search for wood and animal feed. It takes about three hours for the return trip, and it’s relatively common for women to be intercepted by groups of bandits (usually men with guns), and have their things stolen or worse. Emotional, physical, and sexual violence are experienced by many (about 10%, by my general polling of the CHW’s), with rape and other forms of brutality affecting 2-3%. Having men with the women leave the camp together makes it safer, but collecting wood and feed “is women’s work,” and men will generally not do it. I’m not sure if I went red in the face, but I felt an impulse of rage when I heard this. Could it be the case that men would rather their wives and daughters were beaten and raped rather than suffer the indignation of taking a morning walk together to collect necessities?!?” On further inquiry, I was told that men suffer beatings (their teeth are broken, for example) if they stand up to groups of bandits. This morning’s story was of a local Chadian woman who stole a large bundle of straw from a Sudanese woman walking back to the camp, insulting her all the while. Later in the week, the Chadian woman was seen wandering through the refugee market-place (that operates on Mondays and Thursdays). The local police were called and some sort of questioning was undertaken, but with no evidence, her denials were enough. No good solutions to the problems of violence were discussed. As I listened, I recognized that most were quite pleased that the numbers of those affected were “so low.” It is of course outrageous that multiple beatings and rapes a day is considered an improvement. The next person waits to speak…

5) In the last two distributions (by SECADEV) there has been no soap. Basic hygiene, the backbone of medical health, is not being attended to, and people are rightly upset. I have been in Abéché and N’Djamena recently, and there was LOTS of soap in the markets… and nobody spoke of supply chain problems. This will have to be looked into.

So, this is what was discussed over an hour and a half. Basic needs: safety, hygiene, medical care.

For the past few days I have tried to just take things in, asking as many questions as I can. There’s a lot going on. My plan is to try and get a fix on who does what and what they say about it. It is going to take a while, and it is for this reason that I’ve stalled on writing about mental health, which I will do soon. On first pass, so far, the concerns are very pragmatic.

Every place has something that makes it unique. The background that provides the relief against which all is made contrast, visible, and dynamic. It does not tell a story, but it is the timbre of the voice in which it is told; the flicker of the flame that holds us rapt for hours; the scent that ushers in a distinct memory that we’d long forgotten that we ever knew, and transports us entirely. It is not sustenance, but the flavour that we recall. Not music, but the silences that circumscribe rhythm and cadence. I have been here for three cycles now, and from morning to night, it is becoming clear that in Farchana, all stories start with the sky. It is a soft, back-lit, baby-blue hue that has been washed a thousand times over and clings onto its brilliance still.

It feels that all that springs forth from this harsh land has been carved from the sky, sitting atop a flat and dusty soil, like miniatures on a piece of softly curving sandpaper: the adobe and straw walls that demarcate the small squares of land allotted to each Sudanese refugee family, the tents constructed by myriad NGOs to house food and supplies; the wood and plastic-sheeting structures that offer sitting areas and consultation rooms for the sick, the malnourished, and those seeking mental health or perinatal care; the concrete slabs that look like a heavy strip mall in the early stages of construction that serves as the school; the water pumps at which women in brightly-coloured swaths of fabric move to and fro with large pots and buckets balanced on the heads, small children in wobbly tow; the thatch-roofed tukuls in which we sleep; the wandering donkeys and occasional chicken; the thorny brush.

This morning, the sky opened up as it has every day since I arrived; it is impossibly large, stark, and embracing. It defies us to enter into it, and we do, out of our camp, through the mango grove, over the dried up wadi (the water, I’m told, still runs a few metres beneath the sand), through the small town of several stalls, and into Farchana Refugee camp.  About 22,000 resident Sudanese refugees from the Darfur region.

But this is not the story for today. Today was a sad day. The sky witnessed a group of Somali bandits who yesterday attacked some MSF vehicles:

Three dead, including a Somali driver, a Kenyan surgeon, and a French logistician of 27 years.

My condolences go out to their families, friends, msf team, and their communities. And when I say communities, I mean both those from whence they have grown up and onwards, but also the community in the town of Kismayo, near the hospital where the attack took place. I don’t know whether MSF will decide to stay in Somalia or evacuate the other projects, and the situation is so complex that I would not hazard a guess nor valuation. But I do have a sense as to the stability and hope that these projects bring to people. The following is an excerpt of a speech given by David Michalski, the then Head of Mission in Somalia in early 2007, when it was delivered:

Many children die from easily curable disease every day including malaria and respiratory infections. A vast majority of Somalis have no access to health care.

Of course, my description of the humanitarian condition is slanted towards the medical field. However, the situation with regards to education, water and sanitation, and other fields are equally precarious.

In 2006, we performed more than 300,000 outpatient consultations, and 10,000 inpatients were admitted in our hospitals. In general, the quality of the work is verified by high cure rates, low defaulter and death rates. To our regret, we do not have programs in the main urban centers, namely Mogadishu and Kismayo.

This has not meant that our projects are small. In the tiny town of Huddur (approximately 20,000 population), we have the largest inpatient department in southern Somalia with 250 beds full almost every night. Many come from long distances, some traveling for over a hundred miles away to receive care.

(The rest of the speech can be found at: http://tinyurl.com/ywkos2)

At that time, there were over 40 international staff and 600 national staff. They operated in 12 independent sites. I’m not sure how many there are now, but I imagine a similar number if not more. I’ll look into it.

What will happen to these communities if MSF is forced to pull out of this situation, as so many other NGOs have done in recent years owing to the precarious security situation?  When the refugees in Farchana see the MSF logo on a T-shirt or truck, they see that we are actively engaged in their health care.  When the symbol disappears for a few days, or regular health care clinic hours are not met, for example, it is worrisome, and deeply so.

Anne Frank once remarked, while observing the extent of human depravity in the second world war, that “humans are really good at heart.” While I suspect that Anne herself was good at heart, and saw the world that way, I think that she was wrong. Some are, many are not, but there is a remarkable plasticity. We know this by opening up a newspaper, by flicking on the TV, and by listening to anyone with stories to tell. Which is pretty much everyone. Humans are capable of terrible things. Experiments by Philip Zimbardo and Stanley Milgram suggest that you can take an otherwise respectful and ethically-minded person and, in the right circumstances, turn them into an obedient animal, quickly capable of cruelty, cunning, degradation and actions approaching torture. We can likewise fashion ourselves into caring, compassionate and generous persons, looking out for our brother, neighbour, countryman and beyond. This malleability of spirit has been co-opted by those who inspire us to use our superpowers for good. Stability borne of living wages, accountability (the rule of law), and hope for tomorrow by having our basic needs met.

This morning I walked along in our small compound, returning to my tukul after brushing my teeth, and found Bienfait, our Congolese doctor, talking on the satellite phone. He seems to be one of those people who Anne Frank was talking about. A teardrop rolled down his cheek and his eyes welled red as he told us of the news from Somalia. To my mind, his tears were for those that died, and for the suffering in Somalia that may come for many.

The journey to Farchana is moving along at the pleasant pace of a water-logged pinball. I was expecting a one-day turn-around time in Abéché, but the logistics just worked out such that the scheduled departure is on Friday, so it’ll be a four-day wait here. Our Abéché-departing Land-cruiser met the one sent from Farchana at a half-way point to transfer passengers in both directions. This operation, done twice a week, is uniformly and rather endearingly called “the kiss.” As much as I’m psyched to finally get to my project, I’m finding these extended layovers a great way to get a feel for how MSF operates. Today’s briefings were on security and the regional politics in eastern Chad, and it was no gloss. Lots of details, but I won’t write reflections or a description on this. (When I did, in a previous post, it was edited out by someone in Germany. And just for the record, while it chafes to be censored in any sense, I am not upset, nor particularly surprised. My writing was noted to be too political and, at times, variably factually uncertain or too accurate. C’est la vie. It is the mark of expertise to speak broadly on a complex subject while still maintaining accuracy; needless to say, I’m not there for the most part, and when something may be an accurate comment on the facts in the ground, that statement itself may not appropriate for blog treatment).  Learning.

So I’ve got time to dither, and when I’m not playing scrabble on my laptop (about eight games today… it’s coming out my ears, and I dream of anagramming words at night) I’ve been musing on the set-up here, and getting to know some of the in-country management team better. I’m having a hard time understanding the French spoken by the Chadians, mostly because of my poor ear for these things, and in part because of the dialect. It’s going to be a slog to function in French with the team in Farchana.

 

Abéché: the most pervasive environmentally trenchant fact about this desert town, which is the largest in eastern Chad, and it’s second largest city, is dust.  No paved roads, no grass, just dry earth. It feels like how I imagine Marrakech would have been in the early-mid1900s, but with cell-phones and white Land Cruisers. We’re in the heart of winter now, and it’s actually pretty chilly at night (about 15˚C), while the days get up to 27 or so. I awake to the sounds of birds chirping, and from the tin door of my small room at the compound, I can see streams of them lined up on the coils of barbed wire. While walking from the sleeping compound to the office, there is a chorus of chirping while they flit from barbed metal to spaces between shards of broken glass embedded on the tops of the walls. It’s a rather cheerful sound, if but a heady image, and if you add their stochastic hum to that of the generator and the occasional yelping of the new puppy (named Tonto), you have the deep soundtrack to morning life here.

I’m trying to figure out who the other people are who are on the airplane.  It is a 100-person flight from Paris to Chad’s capital, N’Djamena.  The fellow sitting beside me works for Exxon, and at the airport he and many others are greeted by people holding Exxon placards with various names on them.  As well, people in military fatigues are greeting other passengers.  Military, oil interests, humanitarians, missionaries.

A young fellow with a bright smile that shows all his teeth wanders calls out my name and looks relieved to have found me. “Papi” introduces himself and takes me directly to the bar, where I meet the administrative coordinator (AdminCo) who seems a bit fatigued, but offers me a beer almost before saying hello.  This is a good thing.  We chat briefly before heading back to the MSF compound, and I’m shuffled into the back of a 4X4 and we zip off.  Very quickly, however, we’re off paved roads and traveling slowly on bumpy ground in what looks like a sprawling shanty-town.  There is nothing that would betray that this is the capital city of a country.  Nothing.  You know you’re off the beaten path when you’re in the capital city of a country and there’s no Starbucks.  I’m not being anti-corporate, because if there were a Starbucks I would probably be there right now, and it wouldn’t be for the coffee.  As it stands, there is one (count it: ONE!) internet café in the city that the staff here know of, and it ain’t wireless. (The UN people may have wireless…)

Fast-forward a day.

I’m now on the patio under the thatched-roof gazebo.  High white walls topped with barbed wire surround the compound, and there are guards 24/7, without guns, of course (this is MSF… more commentary to come on that). Most neighbourhoods that I’ve seen so far have this look, with the lucky ones having paved roads in front (ours does not). Muslim garb adorns people in the street, with goats and chickens running free amidst the ubiquitous vendors of gasoline (in old 2L drink bottles) and cigarettes. Also common are “recharging stations” for your cell phone. Toyota land-cruisers are the call-sign of humanitarian aid workers, and are surprisingly common, emblazoned with large identifying logos.

As it turns out, rather than scooting through N’Djamena in a day, I’ll likely not get my in-country “circulation” certificate for a week.  This is due to an unfortunate incident about a month ago wherein a group of French aid workers (working with the group “Zoe’s Ark”) tried to leave the country with 103 Chadian children.  Well intentioned at best.  Woefully stupid, irrespective.

At the training session for this mission, we were give talks by a number of people, but that by David Trevino stands out, probably because he is diva-like in his dramatics, brief, and has one of the best jobs of anyone I know (logistical consultant). He said that there were only three things we had to take from this week: 1) If you want to leave, just say so, and you’ll be on the next flight out, 2) If you are told to leave (ie. you’re being evacuated), don’t argue the point, just go where you’re told and argue later, and 3) never forget that your actions affect other MSF and NGO staff, even long after you’re gone.

It’s this third point that’s the most interesting. I’ve made comments to friends about the “brand management” that is done by MSF. They’re a $400 million-dollar outfit and collect most of it in donations from grandmothers to bake-sales (I’m told this, but it must be more complicated; at any rate, there is a push to deemphasize funding streams from private/governmental sources) . At any given moment, there are about 3000 expats, and many more inpats, in the field, all with the MSF logo on their sleeves, hats, car doors, etc. In this world of viral information transmission, a story or picture can be seen by thousands of people, and have greatly unintended consequences. To this end, in my briefing today, I was reminded that drug use leads to direct repatriation; sexual liaisons with local staff and Chadian nationals are forbidden; that I have to radio my whereabouts at all times; and even that my blog postings must be read and approved before being posted. Usually my big-brother hackles get raised pretty quickly with these things, but not this time. It just strikes me as uber-prudent and well thought-out so far

Non-sequitur: this arabic keyboard is bloody hard to navigate…   damned punctuation.

Well, I was told this afternoon that I may be off to Abeche, Chad (the largest city on the eastern border of the country, about 40km from Sudan’s Western border, the Darfur region.  If all goes well, in a couple of days I could be in the field! The next post will be from Farchana, in shala.

I awoke to the feeling of my thudding heart.  The rate was the same old 55 or so, but it was pounding. This may just be the unholy by-product of malaria prophylaxis and the alcohol from last night’s impromptu dinner party, but it likely has something to do with the fact that I’m off for my mission today.  Packed and stoked, I am! First to Berlin for a briefing, and then Amsterdam for another briefing, and then to Chad on the 17th, I think. Nobody’s given me tickets to anywhere except Berlin, so that’s where I’ll go. I feel like the humanitarian equivalent of a sure thing.

“How are you feeling?”

This is the question that I’ve been asked more than any other (yes, there may be a bias here in that lots of my friends are in the psy discplines…). Mostly, I’ve had a bland response. Other than some non-specific giddiness that could just be gas, my feelings haven’t betrayed (until maybe this morning) an imminent six-month trip to do cultural psychiatry in war-torn central Africa. And I have a guess as to why: I’ve got nothing to compare it to. I’ve never worked abroad, nor have I really travelled in Africa. I was born in South Africa, and immigrated to Toronto when I was 3 years old. And despite heading back every summer for about 7 or 8 years, I feel no more than a vague-yet-oddly-meaningful kinship with the place. A white privileged kid in an apartheid nation cannot validly empathise with the continent any more that a glass-bowl goldfish can with the open ocean. But more than that, I realise that I’m being careful with my assumptions.

“Are you always analyzing people?” / “Are you analyzing me?”

This is probably the most common question I get when I tell people that I’m a shrink. (The second most common is “Are you serious?” to which I like to answer “Hell, who lies about that?… If I was gonna make something up I’d tell you I was a surgeon.” This doesn’t make things less awkward, but somehow it does make it less weird.) The training for this job is 5 years. That’s 3-4 years of medical school, plus an extra five to specialize. It’s a bloody long haul, and a few ingrained habits are (hopefully) beaten out of you, the most entrenched being the idea that you can know something or someone quickly and surely. Yes, first impressions and intuition are invaluable tools, and you’d be a fool to discard them, but they’re just guesses that more often tell you about yourself than the other. As Anais Nin said: “We see the world not as it is, but as we are.” She was clever, amongst other things.  This quotation of hers is one of the very few things I could imagine Wittgenstein ever saying “I wish I’d said that.”

In my view, you gotta listen to a lot before assuming anything to be the case. How many jokes are there about the psychiatrist who just sits there, like some inert rock, for the first 6 months of therapy, repeating in some nauseating voice: “and how did this make you feel.” The kicker is that despite this being some mix of cliché and farce, it’s a stellar question. It’s the answer to this question that hints at who someone is in the world, and you’d often never know otherwise.

When a patient’s partner or parent dies and you say “I’m so sorry for your loss,” it’s more common than you’d think to get a “I’m glad he’s dead… he was an asshole!” in response. Or you congratulate someone for a promotion or accolade, and they only see it as a way for the higher-ups to substitute better pay for some empty title. They’re fuming inside. It simply pays to ask… and although some might consider the question intrusive at best, the short, open-ended question is often the most valuable and telling.  Any hack can jump to a conclusion and think they’re right without testing their assumptions, or grand to their personal choir, whatever form that takes.  It takes a boat-load of active, conscious effort not to do this.

Back to Chad. I’ve simply got no clue what it will be like… I have nothing to meaningfully compare it with; I’ve got no ability to empathise with my projections. Just some vague notion of something coming that’s gonna be big. My dreams have some danger, adventure and disorientation, though, so that’s a place to start guessing, for what it’s worth.  In some way, though, I do feel ready.

If you want to zoom around Chad from the bird’s-eye point-of-view, get Google Earth.  It’s a fantastic programme. (But, if it’s not possible, look at the pictures below.)

If you scroll about, you’ll see Breidjing Refugee camp, made up of approximately 30,000 Sudanese refugees, and Farchana refugee camp, with about 20,000 persons.

The top one is an image from Google Earth, which is the Farchana camp from about 2 km above, and the one below that same camp at ground level. From the UN-map below, you can get a sense as to where the refugee camps are located.

(NB: All of these maps, and frequent updates to the situation in Chad and other humanitarian projects can be found at 1) Reliefweb and 2) the MSF International site.

UN map chad 1

chad map actors on the ground

I don’t know about you, but I can’t think without a map. So, now that you have one, this is what I’m in for starting mid-January of 2008: The plan is that I’ll be stationed in Hadjer Hadid for about six months doing daily trips to nearby refugee camps (mostly Breidjing and Farchana, I think), and IDP (Internally Displaced People; Chadians who have fled violence in their own country) camps scattered around the area. Like most things in life however, and from what brief information I can gather, MSF is an on-the-fly fast-response medical relief organization, so even the best-laid plans can change dramatically and frequently.  The MSF contingent is 8-9 expats, and about 50 national staff.  Not sure about the size of the Mental Health Team contingent, or what the set-up will be.  My mind is racing with possibilities.